Most Medicare Patients Have Co-Payments for Recommended Vaccines

By staff

Washington, DC—The federal government might talk a good game about encouraging higher vaccination levels, but rates remain depressed because many Medicare beneficiaries have limited access to a set of 10 recommended vaccines without having to pay co-payments.

That’s according to a new analysis by the healthcare consulting group Avalere Health. The pharmaceutical industry–funded study determined that about 12% of enrollees in Medicare Advantage Prescription Drug (MA-PD) plans, representing just 4% of overall Medicare Part D enrollees, had access to those vaccines in 2016 without out-of-pocket costs. The percentage was up from less than 5% in 2011, the report notes.

Yet, no standalone Part D plans (PDPs) covered any of these vaccines for diseases such as tetanus and hepatitis A or B without out-of-pocket costs to the patient during the 6 years included in the analysis, study authors point out.

“Rates of vaccine-preventable illnesses are particularly high among older adults,” said Caroline Pearson, senior vice president at Avalere. “While most private insurance plans are now required to cover recommended vaccines at no cost to the patient, very few Medicare beneficiaries enjoy this same level of coverage.”

All of this is despite efforts by federal policymakers to expand vaccination rates, including:

• Healthy People 2020, a national effort by the Office of Disease Prevention and Health Promotion, which has a goal to increase immunization rates and reduce cases of these diseases;• The CDC, which issued recommendations on 17 vaccine-preventable conditions to help guide healthcare providers. • The Affordable Care Act (ACA), which furthered the CDC recommendations by requiring most health plans in the commercial market to cover vaccinations at no cost to the patient; and • Medicare’s encouragement of Part D plans to adopt vaccine tiers with low cost-sharing amounts to promote broader access to vaccines for Medicare beneficiaries.

The study found that, while about 80% to 90% of enrollees in MA-PD plans had a fixed-dollar co-pay for the vaccines, between 47% and 72% of enrollees in standalone PDPs were in plans that used a fixed dollar copay, depending on the drug.

“Medicare has an opportunity to encourage broader use of these vaccines through expanded coverage,” Dan Mendelson, president of Avalere, explained in a company press release. “Options like including vaccine access in existing star ratings program may encourage more Medicare insurers to cover vaccines at no cost to the patient.”